We're always looking to improve our website. If you spot an issue please email: Enquiries@mnsi.org.uk.
The MNSI programme has today, 14 September 2026, launched a new report setting out a number of areas in which care could be improved for women receiving intrapartum care at home.
The report provides a series of safety observations and prompts for NHS trusts on topics such as staffing availability, training and guidance, and communications between different care professionals.
The publication is based on learning and insights gained from the analysis of 59 maternity investigation reports (produced between 2018 and 2025) by both the Healthcare Safety Investigation Branch (HSIB) and MNSI. These investigations are carried out when they meet MNSI criteria and relate to early neonatal deaths, stillbirths and severe brain injury in babies born at term following labour and maternal deaths in England.
It is important to note that most labours which include care and/or birth at home do not have an outcome that meets MNSI investigation criteria. The report does not compare outcomes across different birth settings nor seek to influence women’s choice of place of birth. MNSI recognises the importance of informed choice.
The report’s purpose is to share learning from completed investigations to support staff and maternity service leaders to strengthen systems, processes and decision‑making related to home birth, alongside existing clinical guidance.
We looked at 59 investigations over seven years. In each case, staffing challenges or delays in recognising emerging risks were contributing factors. This is not about discouraging home births. It is about ensuring home birth services have appropriately skilled midwives, sufficient support, and systems that enable teams to respond quickly when a woman’s or baby’s needs change.
We hope that the review’s findings will inform and support the other national work, led by NHS England, to develop resources that enable services to consistently support commissioners, providers, and women and families, relating to the provision of homebirth services.
The report has highlighted eight key theme areas for trusts to consider:
This review shows what happens when home birth services do not have enough staff. Midwives should never be without support if a labour becomes complicated. Delays in recognising when a mother or baby needs hospital care can have serious consequences. Trusts must make sure their staffing and systems match the needs of women choosing to give birth at home.
Women have the right to choose where they give birth, including at home. The evidence and national guidance support this. For women with uncomplicated pregnancies who are having a second or subsequent baby, home birth is associated with fewer interventions and no difference in outcomes for the baby compared with an obstetric unit.
“This report is a stark reminder of the consequences when maternity services are not staffed safely. Midwives want to provide the highest standard of care, but they need the time, resources and support to maintain their skills and meet the needs of the women and families they care for.
“Alongside the recent NHS England review and learning from coroners’ cases, this report must act as a catalyst for change. Maternity services across the UK need the investment and support required to ensure women can make genuinely informed choices about their births and that midwives are able to provide safe, high-quality care in every setting.
PDF, Size: 773.2 KB